Tube Feeding in Patients With Advanced Dementia

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TUBE FEEDING EFFECTIVENESS IN DEMENTIA vival was found between groups treated with and without tube feeding among 1386 patients with recent progression to severe cognitive impairment. This findingpersistedafteradjustmentforage, prior history of pulmonary aspiration or stroke, presence of swallowing disorder, decubitus ulcer, functional state, resuscitation wishes, and cognitive status. 37 A separate article based on the same data set described 5266 residents with chewing and swallowing problems and reported a significant increase in 1-year mortality among tube-fed patients (risk ratio, 1.44). 38 Wefoundnopublishedstudiessuggestingthattubefeedingcanprolongsurvival in demented patients with dysphagia. ARE PRESSURE ULCERS PREVENTED OR IMPROVED BY TUBE FEEDING Data linking poor nutrient intake or abnormal markers of nutritional status to pressure ulcers are extremely limited. In a 1995 review 39 that excluded orthopedic and spinal cord injury patients, 13 studies found very weak associations between nutritional status and pressure sores. Data relating nutrient intake to pressure sores were similarly inconclusive. No prospective trials of tube feeding were found, and retrospective studies found only an increased risk or no benefit associated with tube feeding. 39 A MEDLINE search of enteral nutrition and decubitus ulcer from 1966 through March 1999 found no controlled clinical trials of tube feeding in those with or at risk for pressure ulcers. Two studies that used an administrative database of more than 800 patients during 6 months of follow-up reported that tube feeding was not associated with healing of preexisting pressure sores, 40 nor with protection from new pressure sores. 41 Bedfast, incontinent patients with dementia who are tube fed are more likely to be restrained 42 and will probably make more urine and stool. Pressure sore outcomes could be worsened. We found no published studies suggesting that tube feeding can improve pressure sore outcomes. IS THE RISK OF OTHER INFECTIONS REDUCED BY TUBE FEEDING Aspiration pneumonia and pressure ulcers, conditions that are sometimes infectious, have already been considered. We searched MEDLINE from 1966 through March 1999 using the terms enteral nutrition and infection and limited our search to studies involving humans. We found no studies of tube feeding to reduce the risk of other infections—eg, urinarytract,viral,gastrointestinal,oreye infections. In contrast, feeding tubes can cause infection. Nasogastric tubes predispose to infections of the sinuses and middleear.Gastrostomytubeshavebeen associated with diarrhea (infectious and noninfectious), cellulitis and abscess (at a rate of 3% to 8%), and rarely with necrotizing fasciitis and myositis. 43 Enteral feeding solutions can be contaminated with bacteria, perhaps leading to gastrointestinal symptoms. 44 Case reports have described streptococcal bacteremia followinginsertionofaPEGtube 45 andcontaminatedenteralsolutioncausingnosocomial bacteremia. 44,46,47 We found no published studies suggesting that tube feeding can reduce the risk of infection in dysphagic patients with dementia. CAN TUBE FEEDING IMPROVE FUNCTIONAL STATUS Providing an emaciated patient with artificial feeding is sometimes intended to improve strength, function, or selfcare. We reviewed a MEDLINE search of the terms function, functional status, recovery of function, strength,oractivi- Table 1. Mortality After Feeding Tube Placement: Observational Studies* Study, y Intervention Type of Patient, No. Outcome Heimbach, 28 1970 Surgical feeding tube Neurogenic, 100 63% Mortality by 1 mo Matino, 29 1981 Jejunostomy tube Neurogenic, 54 33% Mortality by 1 mo, 50% mortality among survivors by 6 mo Golden et al, 30 1997 PEG tube Mixed population, 102 24% Mortality by 6 mo, 55% mortality by 2 y Kaw and Sekas, 31 1994 PEG tube Mixed population, 46 20% Mortality by 1 mo, 59% mortality by 18 mo Hull et al, 19 1993 PEG tube Mixed population, 49 8% Mortality by 1 mo, mean survival 6 mo Kohli and Block, 20 1995 PEG tube (review of 4 studies) Mixed population, 612 16%-30% Mortality by 1 mo Nevins, 21 1989 PEG tube or gastrostomy tube Neurogenic, 22 41% Mortality by 3 wks Fay et al, 32 1991 PEG vs nasoenteric tube Mixed population, 109 50% Mortality by 4 mo for both populations Hassett et al, 22 1988 Gastrostomy tube Neurogenic, 87 20% Mortality by 1 mo, 40% mortality by 1 y Grant et al, 23 1998 PEG tube or gastrostomy tube Mixed population, 81 105 24% Mortality by 1 mo, 63% mortality by 1 y, 81.3% mortality by 3 y Finocchiaro et al, 24 1997 PEG tube Mixed population, 136 9.5% Mortality by 1 mo, 58% mortality by 1 y, 65% mortality by 2 y Loser et al, 33 1998 PEG tube Mixed population, 210 66% Mortality by 1 y Fisman et al, 34 1999 PEG tube Mixed population, 175 18% Mortality by 30 d, 61% mortality by 1 y Light et al, 35 1995 PEG tube Mixed population, 416 9% Mortality by 1 mo Bergstrom et al, 36 1995 Gastrostomy tube Mixed population, 77 21% Mortality by 1 mo, 64% mortality by 1 y *Neurogenic indicates dementia, cerebrovascular accident, trauma, anoxic brain injury, Parkinson disease, Guillain-Barré syndrome, or motor neuron disease; PEG, percutaneous endoscopic gastrostomy; and mixed population, patients with neurogenic mechanical disorders and cancer. ©1999 American Medical Association. All rights reserved. JAMA, October 13, 1999—Vol 282, No. 14 1367 Downloaded from www.jama.com at MEDICAL LIB on December 15, 2008
TUBE FEEDING EFFECTIVENESS IN DEMENTIA ties of daily living, and enteral nutrition from 1966 through March 1999. In stroke patients, emaciation may be associated with slower functional improvement, 48,49 but we found no study in which a nutritional intervention facilitated recovery of function. Among 100 frail nursing home residents, oral protein supplements produced no improvement in measures of strength or function unless combined with resistance strength training. 50 A retrospective review found that no nursing home patients had improvement in functional status as measured by the Functional Independence Measurement scale during 18 months after PEG tube placement. 31 We found no published studies suggesting that tube feeding can improve function or mitigate its decline in dysphagic demented patients. DOES TUBE FEEDING IMPROVE PATIENT COMFORT We searched MEDLINE from 1966 through March 1999 using the terms palliative care and enteral nutrition. For many demented patients, data about symptoms and symptom control can be based only on inference. In a prospective observation of palliative care for terminally ill patients with anorexia, primarily with cancer or stroke, few experienced hunger or thirst. Of those who did, relief was achieved with small amounts of food and fluids or by ice chips and lip lubrication. 51 Patients with amyotrophic lateral sclerosis and dysphagia who had feeding tubes placed continued to cough, have difficulty managing oral secretions, and develop aspiration pneumonia. Hunger and nausea often began or increased after tube placement, and human contact was diminished. 52 Tubefed patients may be denied the pleasure of eating or made uncomfortable by the tube or frequent repositioning; some require restraints. We found no published studies suggesting that tube feeding makes dysphagic demented patients more comfortable. ADVERSE EFFECTS We searched MEDLINE from 1966 through March 1999 using the terms complication and enteral nutrition and limited our search to studies of humans age 65 years or older. The many adverse effects of tube feeding have been divided into 4 major categories: local or mechanical, pleuropulmonary, abdominal, and other (TABLE 2). The most common adverse effect associated with all types of tube feeding is aspiration pneumonia (0%-66.6% 5 ). For PEG tubes, common adverse effects are tube occlusion (2%- 34.7% 19,31,37 ), leaking (13%-20% 31,32 ), and local infection (4.3%-16% 19,31,32,60 ). Approximately two thirds of nasogastric tubes require replacement. 32,68 CONSERVATIVE ALTERNATIVES Discontinuing nonessential medications may reduce eating difficulties. Among psychiatric patients, swallowing dysfunction and choking have been associated with certain medications, especially those with anticholinergic effects. 71,72 Several drugs cause inattention (eg, sedatives), movement disorders (eg, major tranquilizers), xerostomia (eg, anticholinergics), esophagitis (eg, alen- Table 2. Burdens and Complications Associated With Tube Feeding Adverse Effect Category Local/mechanical Pleuropulmonary Abdominal Other Type of Tube Nasogastric Gastrostomy and/or Jejunostomy Both Erosion/necrosis, bleeding of nose, pharynx, and/or esophagus 52,53,55 ; postcricoid perichondritis 54 ; tube misplacement into lung or brain 43,56 ; high extubation rate; otitis media; sinusitis Tracheoesophageal or bronchopleural fistula 55 ; hemothorax, hydrothorax, pneumothorax 53,55,57 ; tracheobronchial perforation; pneumonitis, lung abscess; pneumomediastinitis; airway obstruction; infusion into lung Perforation of esophagus or duodenum; esophageal stricture; esophageal bezoar 58 ; reflux esophagitis Agitation 53,68 ; requirement for frequent repositioning; increased secretions or frequent suctioning Wound dehiscence; bleeding at insertion site; closure or stenosis of stoma; skin excoriation; hematoma; erosion of bumper into abdominal wall Erosion of tube into pleural cavity Knotting of tube; tube malfunction 64 ; tube migration; discomfort from tube; tube placement failure Aspiration of feeding Gastric perforation 60 ; gastric prolapse; Diarrhea; gastrointestinal bleeding 62,67 ; gastrocolic fistula 59 ; pneumoperitoneum; bowel obstruction 64 ; nausea 62 ; pneumatosis intestinalis 61 ; prolonged vomiting; promotion of ileus; evisceration 62 ; acute gastric gastroesophageal reflux 70 dilatation 65 ; intussusception 66 ; gastric wall defects 66 ; laceration of esophagus 54 ; peritonitis 54,60,64,67,68 ; cellulitis 59,62 ; necrotizing fasciitis; abdominal or subphrenic abscess 67 Arrhythmia 26,62 ; laryngospasm; shock; mediastinitis 62 Fluid overload; increased skin moisture; death; use of restraints 63,68,69 ; weight loss 53 ; metabolic disturbance 53 ; loss of gustatory pleasure; anorexia; loss of dignity; loss of social aspects of feeding; altered cosmesis 43,59 1368 JAMA, October 13, 1999—Vol 282, No. 14 ©1999 American Medical Association. All rights reserved. Downloaded from www.jama.com at MEDICAL LIB on December 15, 2008
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